Attachment V - EMR Form.pdf
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- Solicitation number
- 36C25024B0021
About this file
This document contains a pre-award contractor safety evaluation form and details of a federal contract opportunity for corrective work at a Veterans Affairs medical campus. The evaluation form requests contact information and safety data including total man hours, OSHA recordable incidents, days away from work rates, and violations over the past three years. It asks for NAICS codes and safety program administration. Contractors must provide their insurance experience modification rate.
The federal contract opportunity is to install waterproof coving and complete related site work at Building 8 to correct water intrusion issues. The work includes excavation, backfilling, road and sidewalk repair, drainage work, landscaping, and pavement markings. All work must be finished within 365 calendar days of the notice to proceed. The contract is through the Department of Veterans Affairs for the VA Northern Indiana Health Care System Marion Campus.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C25024B0021:
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2020 2021 2022
Number of man hours (jobsite and office).
Number of cases involving days away from work, restricted activity, or both (Column H and I of OSHA 300).
Days away, restricted, or transferred rate (# of days away, restricted, or transferred cases x 200,000/# of man hours) (DART Rate).
Number of serious, willful, or repeat violations from OSHA within the last 3 years. Please attach explanation for any violations.
Please attach copies of the following documents: OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html.
2. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
3. Who administers your company’s Safety and Health Program?
4. Company’s Insurance Experience Modification Rate
(EMR): ____________________________
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .